Monthly Archives: February 2019

It used to be that, in the winter, we’d sometimes get up at four AM to fetch water. When the tap nearby in Deurali would dry out due to the dry weather, or the tenuously protected pipe sourcing it would breaksomewhere along its many kilometers between Dhampus and Kaskikot, we’d have to go further downhill to the natural spring in Rotepani.

Deurali

In the summer, Rotepani was so rich with water that people filled their tin water jugs freely under gushing, splashing geysers while others bathed and did laundry and on the surrounding rocks, submerged up to the knees, cooled in the August heat. But in the dry season, sometimes even Rotepani would slow to a trickle from two out of three pipes that protruded from a cemented tap. The gushing natural spring that pours directly over the rocks would evaporate. Sometimes the line for water took half the day.

During those times, Saano didi and Neru would wake up before dawn and come up the path to our house. Aamaa and I, and Bishnu while she was still here, would join them with three baskets slung from our heads loaded with every jug and bottle in the house. We’d pick up Maya Bouju as we passed her house and walk single file along the edge of Gita Bouju’s wheat field. With the hills still shadowy along the southern horizon we’d cross the dirt motor road, make our way down a steep stone walking path to arrive at Rotepani in the dark, and help each other fill all the containers trickle by trickle. Then we’d walk back up the hill, pour the water in to slightly larger vessels in each of our homes, and turn around to do it again. Each trip took about 45 minutes, and we’d make three or four visits before the sky stretched open its arms to reveal another morning.

There have been times when water takes up the majority focus of attention in the household functioning. When pipes break in Deurali, when the weather is dry, when the buffalo is ill, when there many guests, or when there are very few residents to share labor; all of these lead to an immediate and exacting calculation of how much water is in the house, how long it will last, and what amount of physical labor is required to replenish it. Sometimes it’s one person’s job to ferry water for hours at a time. When I’m here, I tend to gravitate toward the water carrying—a fairly straightforward, essential, and never finished chore.

Over the last year or so, recent changes in the government have led to mumblings about piping water to the yard of each individual home. In sixteen years, I’ve seen many changes come through Kaskikot…new two-story cinderblock houses, paved road, the occasional wifi connection, a completely transformed economy from subsistence to remmittance. Cellphones, Facebook, TVs, hotels, cars. Many of the houses around us in Kaskikot have already rigged up pipes that they can attach to the Deurali tap when it’s not in use, offering a continuous stream of water that passively fills an enormous polypropylene tank in the yard.

We have a tank, but like the enclave of about four houses near us—including Saano Didi’s and Mahendra’s houses—we still have to carry water to it. Our water situation remains basically unchanged. We still take baskets to fetch our water from the tap in Deurali five minutes away. When Deurali is dry, we still go to Rotepani, 15 minutes away. On occasion, when Rotepani is too busy or the flow of water is almost dried out, we walk windy footpaths half an hour down to the fields in Dadapari and use a cup to lift water from a natural pool under the rocks. A few times, I’ve accompanied Aamaa to do a household of laundry on flat stones there.

Aamaa, of course, is sixty-two and lives alone most of the time. So by “we,” I mean Aamaa.

Last summer as I was leaving in August, somebody arranged to rig up a pipe that had been brought from Deurali up to the crest of the ridge by our house. Its location wasn’t in our yard, but it was only a up on the ridge, about seventy-five yards away instead of five minutes in each direction. The day I was leaving for the U.S. was the same morning that this new pipe was first hooked up, and all our closest neighbors clamored about filling buckets and oil gallons and jugs while Mahendra’s father BAA! presided over the fray. Any moment that the pipe was unattended, it sprayed wild streams of water that swirled in to muddy rivulets down the side of the hill and in to Khemraj sir’s corn field. Little Narayan and Amrit were ecstatic with the newfound responsibility of presiding over a line of eager adults and aiming the unruly three-headed pipe head as it washed dirt off the footpath and down the hill.

When I arrived back this week in January, I discovered this setup slightly relocated but similarly conceived. With water much more spare in the winter, each household has been assigned to use it on alternating days. When we got up this morning, it was our assigned day. Aamaa began fretting about it last night. I assured her that I would take water duties in the morning, which is fine, but the problem is that for reasons I couldn’t determine, she wanted to get cracking at dawn, and one thing that’s changed in the last ten years: I am no longer so interested in proving something that I am am motivated to get up before dawn. I am happy to prove my value during daylight hours.

Lucky for both of us, for some reason the water didn’t become available this morning until 9am. Having slept until American hours and had my tea, I dutifully began the water retrieval process. Pascal helped me bring all the water jugs and bottles and even buckets up the hill, where we set them down beside Maya Bouju’s house to wait our turn.

Saraswoti was there of course, and Jivan’s young wife Bal Kumari, and BAA!, and everyone had brought literally any item in their house that could hold liquid. The issue–and the thing is, I’m American, I’m trained to spot potential matters of inefficiency and to fret about them–was that the pipe itself was barely producing a trickle. So filling the army of receptacles from our three households was a phenomenally lengthy task that quite literally involved watching water drip for long, yawning minutes. And minutes. And more minutes.

I squatted down next to my pals Saraswoti and Bal Kumari. They were perfectly happy with the distraction, the pace of the task, the opportunity to sit on a hill and chat or not chat and pick at blades of grass. I was like, “Yo you guys, it’s going to take me approximately one million years to fill all this stuff.” My gaze drifted to the footpath. Four minutes away was a perfectly functional, largely unmanned water tap.

I calculated that in the time it would take Saraswoti and Bal Kumari’s water jugs and buckets and bottles and gallons to fill in front of mine, I could easily take a jug to Derail, fill it, bring it home, and bring it back here for a second filling.

“Just wait, Laura, it won’t take too long,” Saraswoti assured me, despite the fact that this was plainly inaccurate advice.

“I’m just going to go…um, fill this jug and come back,” I said. I did. When I came back, my other six jugs and buckets and bottles were still waiting in line. Bal Kumari had left and Saraswoti was taking her turn.

“Have a seat, Laura,” Saraswoti said. I sat. Saraswoti and I watched the water drip lazily, its splashy pitch changing as the surface level crept up the inside of the tin jug. The winter mountains pierced the entire panorama of the northward sky, and to the south the hills were clear and fresh. When it was my turn, I filled our jugs, took them home, dumped them in to the tank, and began the whole process again.

Of course, Bal Kumari was back.

“Laura didi, it won’t take long,” she and Saraswoti assured me. Given that the water hadn’t become more abundant, this statement had also not become less untrue. I couldn’t take it. I took one jug off to Deurali, repeating the entire process as before.

As my trips accumulated, so did the various filled containers in the yard. The tank filled. Aamaa has recently installed a recycled oil barrel that comes to my chest; it was filled. At intervals, Pascal was reluctantly cajoled in to retrieving filled bottles and buckets from and dumping them out at home and returning them to our muddy hill. The tubs and emptied kerosene gallons were filled. Each time I thought I was done getting water, Aamaa would find another centimeter of space inside some container or another and make an entire four liter tin jug of water disappear in to it. I started to get annoyed, and then I started to giggle. The teapot, after all, was still empty.

I couldn’t help but think of when our only containers were two tin jugs, a leaky plastic box, and two small lotos. By comparison, there was now enough water in the house for all of us to bathe five times and do a midnight water puja under the moon. But Aamaa kept finding more spaces to add water and sending me back to the maddeningly dripping pipe by Maya Bouju’s house.

“Aamaa, I think–” I wanted to point out that the tap in Deurali was currently available daily. Why was I an indentured servant to the drippy pipe by Maya bijou’s house, today, just because it…existed?

“It’s so much closer,” Aamaa said. “If the tap dries up, I’ll be without water,” she explained. I found this both entirely logical and entirely illogical at the same time. It couldn’t be solved. It reminded me of the time that Bishnu and I had dozed off in the middle of the afternoon with Pascal lying between us when he was a baby, and we woke up to find the lights on in broad daylight amidst the ruthless load shedding schedule; Bishnu yawned groggily, “Hey when the electricity is available, we have to utilize it.” This immediately launched me in to fits of hysterical laughter for the next ten minutes and I would lose it every time I thought about it for years. Now, I also knew the only thing to do was keep getting more water from the pipe on this, our assigned day. The opportunity was not to be missed, irrespective of any broader analysis about overall benefit. And while I claim to have nothing left to prove in Kaskikot, let’s face it: where the rubber meets the road, I still have too much pride to throw in the towel early.

The only way out was to prove this labor was unwarranted.

“Aamaa, are you gonna take the cups out of the kitchen and have me fill them up too?!” I cried, half joking and half serious. Truthfully, I wanted to sit around and read. I resented this unreasonable purgatory, even though I not only signed up for it voluntarily, but also understood that it technically started and ended far away from the pipe by Maya Bouju’s house. I didn’t want Aamaa to have to haul water tomorrow or really ever. It just seemed to me, like, you know, we totally had lots of water.

Finally, when our entire yard was ringed with anything that could be turned in to a basin or pitcher, each brimming so high that the act of dipping a cup in it would spill a few steps worth of hauled water, I put the basket and rope down on the porch.

The buffalo honked lazily. It was mid-morning, and the day stretched bright and clear in front of us.

“They say,” Aamaa mused to nobody in particular, “that we’re each going to have our own water tap. I brought the pipe here already. But I’m not allowed to connect it up to the yard.”

The second half of our winter professional development is focused on treatment of older adults. Even though a lot of treatment that dental technicians do is in schools, during the weekly dental clinic at the Health Post, they mostly get adult patients. And since most rural adults have had little or no dental care, and likely weren’t exposed to fluoride toothpastes or other preventative measures for their first few decades of life, some of the conditions that present in our rural clinics are pretty extreme. Besides that, tooth loss in older age is common enough that it’s more or less expected.

Of course, our technicians can refer older patients to higher care, and they do. But following up on referrals isn’t always that easy, especially for older folks with reduced mobility. Not to mention that rehabilitation of many mouths we see in elderly patients would require months of ongoing, expensive, complex treatment even in a state-of-the-art dental hospital–something that’s simply is not feasible for the majority population even in a first-world city. So here we are in rural Nepal working in primary care, which is about disease prevention and improving quality of life. But save for the occasional extraction, older adults are mostly left out of the process when it comes to primary oral health care: directly related to the ability to eat, sleep, and participate socially. If we can relieve pain and preserve teeth longer, that seems like a solid contribution.

With this in mind, we wanted to develop a professional development workshop on how the simple techniques that we’re already using – glass ionomer, silver diamine fluoride – can be used to help relieve the diseases experienced in older populations in Nepal. By “we” I mean Bethy since she’s the one obviously who did this because I write stories about teeth and she is a public health dentist. And even if you’re not a dentist or especially interested in cariology, I have to say that how this turned out is really pretty cool.

A few years ago, Bethy and Keri took photos of about 65 people who’d had restorations done in our clinics, and we used these as the basis for a quality-of-care assessment. It resulted in a few different things. One was adding some missing instruments. Another was noticing an apparent pattern among older adults where, around middle adulthood, adult teeth begin to wear rather than decay. It might be caused by anything from an acidic diet, to abrasive brushing with spices, to a lifestyle change like a new medication. The lower part of the tooth near the gums wears down and become loose, causing sensitivity and difficulty eating, and gradually, the teeth simply fall out. These are the adults who, right now, are getting no care at all besides the occasional extraction. They were the focus of our training.

Our technicians practiced placing glass ionomer restorations on the root-surface lesions, near the gums, that so often lead to tooth loss in older adults. Bethy explained how an event in the life of a middle-aged adult, such as an illness, can cause a simple change like dry mouth that alters the whole environment and leads to deterioration of a previously resilient set of teeth over the next period of years.

I loved this workshop. For the first two hours, instead of looking at teeth, Bethy brought in pictures of older people and the clinical teams simply talked about aging. What makes people old? Are all old people the same? Do they have the same priorities and daily demands and ideas of self? What do we assume when we see someone who we think is “old”? How does a person’s identity factor in to how we work with them to improve their lives? What is our responsibility to someone’s dignity?

In preparing for the workshop, Bethy and I mined our respective photo archives for pictures of elderly people in Nepal and Cambodia. One by one their faces stared out at our group of clinicians, suddenly daring: Who do you think I am?

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In the beginning, most participants had a sort of default position that older people are weaker and less capable of handling dental treatment. But as we went through the photos for well over an hour, stories blossomed. In some cases, they were people whose backgrounds we knew- my neighbors in Kaskikot, steely women I’d photographed during our work after the earthquake in 2015, caretakers and weavers and shopkeepers who’d given interviews in Bethy’s surveys in Cambodia. Bethy used a clever framework called “Go-go, go-slow, no-go” to talk about what each of these people might be expecting or hoping for from a medical professional. I got to laugh about how Hadjur Aamaa has basically no teeth left and gets around pretty slow, but she’ll put one foot in front of the other to get to the house and then frets the entire day, every day, about the dishes or the peas that need to be shelled; it is absolutely vital to her human essence to be busy with something useful. By the end, our clinical teams were musing over what their patients might be thinking about, who they depended on, and who relied on them, what made them human and alive in the world. This was probably a go-slow patient, like Hadjur Aamaa; this one likely a go-go patient ready to sit there all day and get her teeth fixed; this patient probably wasn’t really about treatment, and mainly needed to have his discomfort acknowledged.

The next day, we returned to the same school in Kaskikot to treat patients age 45 and over. (We’re in rural Nepal, 45 is approaching the pre-elderly group…60 is safely considered “aged” and the point is to catch people BEFORE their teeth are gone.) It was exciting to see the same situations we’d learned about the previous day in the real lives of real people and to be able to offer simple treatments that have the potential to forestall tooth loss for years. The teams continued using the App, entering patient data digitally along side the paper forms.

While patients were waiting outside, the father in law of our local Channeler came by for a checkup. I’ve been to see our Channeler a few times – she lives down near Laushidunga, in the direction of Sada Shiva where I taught primary school for a year. The story that’s told about the Channeler is that she suffered terribly from a kind of delirium for a period of time. She was treated in a hospital, but nothing helped. Then she began to channel spirits. She rebalanced. People travel from all over to see her; I’ve brought a handful of visitors there to connect with people they’ve lost. Before Bishnu left for the U.S. in 2008, she went to see the Channeler to connect with her father. The Channeler’s husband has a bum knee, and once I gave him my knee brace from CVS, and he always greets me with an old familiarity when we meet in the road up in Deurali.

Anyway, at some point in the afternoon I couldn’t find our technician K.P., and I walked outside to find he was having his palm read in the waiting area. The Channeler’s father in law spent about an hour reading almost everyone’s palm for fifty rupees each. Everyone–our office staff, the field teams, the schoolteachers and other patients–exclaimed over the things he knew: who’s father had died young, who was still to be married, who was destined to successfully stay with one line of work for a long time (one of our clinic assistants! yay!). I didn’t get a turn because by the time I was ready – I’d had my 50 rupees in my pocket for like an hour – he’d had enough with palm reading. Palm reading was over.

Still, my most favorite patient of the day was a 93 year old woman who arrived alone. She was frail, used a walking stick, and barely spoke to anyone even to ask them to move out of the way as she plodded through clusters of people like Moses parting the sea. She wore a jaunty white knit cap that stuck up boisterously on her head. Her entire mouth was completely empty except for one jutting molar with an expanse of exposed root.

“How can we help you?” Hira, the Deurali technician, asked.

“This tooth hurts,” the woman said simply.

Hira treated the one tooth with silver diamine fluoride, a completely painless procedure that will hopefully preserve it a while longer and ease her suffering. Then the woman stood up, picked up her walking stick, parted the seas and went home without a word.

This winter our professional development has two parts. Part one is learning to use a new App we’ve been developing with a local startup called Wiseyak. Part two will focus on treatment of older adults in a rural setting.

Our still-to-be named App is designed for use with the Basic Package of Oral Care in Health Posts (or potentially any primary care center in a rural, limited-resource setting). Bethy and I have been meeting with the developer, Ravi, for a few months, discussing how an App can be most beneficial our environment, where public health needs are paramount. What exactly is the role of technology in a Health Post in rural Nepal? Should it help with smart diagnostics? Facilitate “telemedicine” where midlevel providers in remote areas consult with doctors (a hot area of tech innovation that I feel some feelings about)?

We weren’t trying for either of these. I felt strongly that the greatest need in our rural clinics isn’t producing technical magic between provider and patient. For one thing, the logistics are scratchy: most Health Posts can’t rely on a stable cellular connection, much less fast WiFi. But the main reason is that dental technicians should have good training and expertise equivalent to their responsibilities. Why invest in an app instead of improving the skills and abilities of the operator?

Instead, our App is simply designed to provide excellent documentation. Good digital record keeping offers a wealth of valuable opportunities. It can help us track specific conditions at population level (in case you’re into dentistry, which I’m kind of not, that would be things like decay on first permanent molars in schoolchildren). Rather than medical technology to help to diagnose disease, it’s designed to facilitate documentation of treatment plans over multiple visits and make it easy for technicians to follow-up with patients in their villages. The App should also be able to spit out referral lists to higher care and provide urban centers with referred patients and contact information. And last but not least, as a health surveillance tool, it will allow us to scan aggregate data and identify specific needs in different areas–and because we are using a community-based and rights-based design, the issues we’re tracking are those that can be addressed with skills that the technicians provide right there in the primary care system (again, in case you’re in to dentistry, that would be things like silver diamine fluoride, ART and sealants).

So in a sense, our App is a much as social justice technology as a medical or public health technology.

It was kind of a thrill to kick off our training on the App yesterday. Bethy gave a great orientation and had meticulously prepared case studies and patient ledgers for the clinicians to practice entering in to the tablets that we acquired in a great feat of shopping conquery. As is becoming our usual training format, first clinical teams practiced applying the concepts using case photos, which they used to go through the diagnostic process, write the treatment note on paper, and then in this case transfer the note it on to the app. In the afternoon, real patients joined us and the teams worked at super slow speed with lots of time for questions, consultation, and App usage.

The next day, we went to Kaskikot to treat students at a primary school and field test the digital data entry process. Gaurab the Bear joined us and he was an enormous hit. I took some close up photos of young children with severe levels of disease in their mouths, and the next day, the teachers spent a few hours meeting with Bidhya and Shreedhar, our filed coordinators, about re-launching the school brushing program and junk food free school.

We left with a sizable list of adjustments to be made to the App, but it was incredibly gratifying to see how quickly everyone took to using the tablets. We’re aiming to use parallel paper and digital systems for about six months before – hopefully – switching over.